Paul Calabresi Award. From suboptimal to optimal treatment in older patients with cancer. Pierre Soubeyran, MD, PhD

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1 Paul Calabresi Award From suboptimal to optimal treatment in older patients with cancer Pierre Soubeyran, MD, PhD Institut Bergonié, Université Bordeaux Segalen

2

3 Health status-adapted cancer care Balance of risks and benefits Benefits identical whatever age Response to treatment Quality of life improvement Risks higher in the elderly Heterogeneity of problems encountered Age-related physiological problems Elderly-specific problems at baseline cognition, nutrition, functional impairment, social problems, Elderly-specific events during treatment confusion, loss of weight, functional decline, 3

4 Selection criteria in aggressive lymphomas To CHOP or not to CHOP >70 at least one factor among Poor performance status (WHO 3-4) Cardiac contra-indication to doxorubicin Low creatinine clearance (<50 ml/mn) Neutropenia or thrombopenia Severe comorbidities A regional prospective study Soubeyran P, Cancer Treat Rev 2009; 35:

5 How many unfit patients? 189 patients Work-up not completed 14 patients (7.5%) Unfit patients 67 patients (35.5%) 83 patients (44%) Fit patients but excluded from phase II trial 25 patients (13%) Soubeyran P, Cancer Treat Rev 2009; 35:

6 Diffuse large B-cell and peripheral T-cell non- Hodgkin s lymphoma in the frail elderly. Results of the EORTC trial with a progressive and cautious strategy. Soubeyran P, Khaled H, MacKenzie M, Rozewicz C, de Bock R Ceccaldi J, de Jong D, Eghbali H, Rainfray M, Monnereau A, Van Glabbeke M, Teodorovic I. EORTC Lymphoma Group

7 Did we target the right group? YES, we did! o 41% PS 3-4 o 59.4% ADL dependent o 81% IADL dependent o 93.8% GDS15 6 o 37.5% MMS < 24 P Soubeyran J Ger Oncol, 2011; 2: 36-44

8 A cohort study to understand Identification in patients with1 st line chemotherapy of predictive factors for Early death Hospitalization for toxicity Functional decline

9 Which events to predict? 364 patients Early death < 6 m. Odd ratio (95% CI) Functional decline Odd ratio (95% CI) Hospitalization for toxicity Odd ratio (95% CI) Events 59/339 50/299 47/354 Extension (M+ vs M-) 4.1 ( ) Sex 2.62 ( ) Platelet count <150 G/l 3.8 (1,3-10,8) Clinician opinion ns 0.51 (0,26-0,99) PS ns ns MNA ( ) ns 4.19 (1,7-10,3) Get up and go > 20 s 2.51 (1,31-4,82) ns IADL 7 ns 3 (1,13-8,09) GDS (1,23-4,66) MMS ns ns ADL CIRS-G ns Soubeyran JCO 2012 Soubeyran ASCO2012 Warkus SIOG2011 9

10 Prediction of toxicity Martine Extermann, Cancer 2012;118: Arti Hurria, J Clin Oncol 2011;29:

11 Prediction of toxicity Martine Extermann, Cancer 2012;118: Geriatric assessment tools can be useful to manage elderly patients Arti Hurria, J Clin Oncol 2011;29:

12 CGA is time-consuming Screening tools

13 G8 questionnaire Eight questions Performed by a nurse 5 to 10 min Appetite, weight loss, BMI Mobility Mood and cognition Number of medications Self-related health Age Abnormal if 14 Preliminary analysis Se: 89.6% ; Sp: 60.4% Carine Bellera, Ann Oncol 2012;23:

14 The ONCODAGE study Gold standard: Impaired Multidimensional Geriatric Assessment (MGA) Impaired MGA if one abnormal questionnaire CIRS-G : at least one grade 3 ADL : score 5 IADL : score 7 Timed Get up and Go : > 20 s MNA : score 23,5 MMSE : score 23 GDS-15 : score 6 Setting: Patients >70 with cancer Pierre Soubeyran, Proc ASCO

15 Results Geriatric Assessment Duration of CGA 67.7 mn +/ Prevalence of abnormal MGA 80% At least one abnormal questionnaire (Gold standard) Questionnaire with missing question(s) considered abnormal 1435 pts Anormal n % ADL < IADL < GDS MMS < MNA 23, Timed Get up & Go >20 s CIRS-G Grade Pierre Soubeyran, Proc ASCO 2011

16 CGA is time-consuming : screening tools Gold standard: Impaired Multidimensional Geriatric Assessment (MGA) G8 76.6% (74-79) VES % ( ) Impaired MGA if one abnormal questionnaire CIRS-G : at least one grade 3 Time ADL : score 5 (mn) Se Sp PPV NPV K 64.4% ( ) 74.3% ( ) IADL : score % Timed Get up and Go : > 20 s ( ) MNA : score 23,5 91.5% 40.7% ( ) MMSE : score 23 ( ) 37.1% ( ) GDS-15 : score / /- 4.6 Setting: Patients >70 with cancer Pierre Soubeyran, Proc ASCO

17 CGA is time-consuming : screening tools Gold standard: Impaired Multidimensional Geriatric Assessment (MGA) G8 76.6% (74-79) VES % ( ) Setting: Patients >70 with cancer Impaired MGA if one abnormal questionnaire CIRS-G : at least one grade 3 Time ADL : score 5 (mn) Se Sp PPV NPV K 64.4% ( ) 74.3% ( ) IADL : score % Timed Get up and Go : > 20 s ( ) 40.7% ( ) MNA : score 23,5 91.5% MMSE : score 23 ( ) 37.1% ( ) GDS-15 : score / /- 4.6 CGA is useful And screening is feasible Pierre Soubeyran, Proc ASCO

18 Standard Management How to organize? >14 G8 Screening 14 Evaluation and cautious management 18

19 Standard Management How to organize? >14 G8 Screening 14 Selection procedure MGA? CGA? Other? Cautious Management Oncologist + Geriatrician 19

20 How to organize? The French UCOG model CHU HEGP/ CLCC I Curie CHU La Pitié/C Foix CHU H Mondor Geriatric Oncology Coordinating Units 15 already created since 2006 A few more to be accredited soon Bordeaux CHU/CLCC CHU/CL CC Rouen Nantes/Angers CHU/CLCC CH La Roche/Yon Main goals of the UCOG in each region Organize cancer care for older patients Participate to teaching and training Limoges CHU/Cl. Privées Lille Toulouse CHU/CLCC Perform research in the geriatric oncology field Inform patients and public CHU/CLCC CH Senlis/Creil CHU/CLCC/CH Clermont Ferrand Dijon CHU/CLCC/CH / Cl Privées Lyon CHU/CLCC/Cl Privées Marseille CLCC/CDG S C 20

21 Lessons learned - 1 To promote geriatric oncology, we have to convince colleagues with evidence-based data Design of experimental arms should be feasible in the daily pratice Technically and in terms of health professionals Patients included should be close to the reality Participation of community hospitals and private practice Community hospitals should be involved from the beginning of research Implementation in daily practice

22 Lessons learned - 2 Begin with transversal research Then refine tools in each cancer type

23 Finally Still a lot to do! When to propose geriatric intervention? How to take advantage of biological specificities? 23

24 Acknowledgments Investigateurs ONCODAGE

25 Patients

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